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MEDICAL PRACTICE-ITS GRAY AREAS. |
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One
of my dear friends asked me to highlight the achievements
of modern medicine. This is being done daily in medical
newspapers and even in lay press that I need not repeat
the same. This kind of publicity has brought the medical
profession to the level of Gods and playing God had
landed us in deep trouble with the consumer movement. It
is time to take stock of the real situation in the
medical field so that the veil is lifted and the true
picture presented to the " purchaser" lest
there should be misgivings on his part. So far the
attempt has been to paint a very rosy picture of the so
called achievements in the field of curative medicine,
and to underplay the realities. Time has come, with the
changing scenario of consumerism to be frank with the
public. One of my friends had once advised me not to tell
the whole truth to the lay man, but I do not agree with
that view. Now there is an awakening in the field even in
the West, where they want the " purchaser " to
know the truth.
" The fact that medical treatment is not invariably
followed by clinical improvement is not one that those
interested in medical quality- be they patients or
doctors- can ignore." say Dr. William G. Pickering
in his article in the recent Lancet entitled " Does
medical treatment mean patient benefit? " He goes on
to add that " among the diverse selection of
problems presenting to the medical oracle, a proportion-
appendicitis, fractured limbs, and pneumonia- are
unmistakably curable; and success in anesthetics,
fertility regulation, and sundry other specialties add
weight to the inaccurate but extant notion of
limitless medial power." ( emphasis mine ).(1)
There are three kinds of human problems; treatable
diseases which are in the minority,diseases and human
problems for which medial treatment may or may not help
and the third, untreatable diseases. Anecdotal evidence
abounds in showing us that we are fallible but in the
statistical scientific world anecdotes have no place. In
reality they do tell us the sad tale. There is no
incentive to report the uselessness of medical
interventions although they occur regularly. Even in the
eyes of the law if enough doctors practice a particular
remedy, then it becomes right. ( Bolam Vs Friern Barnet
Hospital Case 1957).(2)
Clinical medicine abounds in uncertainty at all levels.
So far the effort has been to sweep it under the carpet
and never face the reality in medical practice. The trend
is changing and there is an awareness now that clinical
decision making is very complex and complicated involving
both rational scientific thinking and in equal measure
intuitive thinking. In fact, Dr. Katz goes one step
further when he says that the doctor’s defense
against ignorance and uncertainty are a greater
difficulty in doctor-patient relationships than the
patient’s ignorance.(3)
In contrast to the usual industrial way of working,
medical practice has always been beset with imprecision
and imponderables, in terms of diagnosis, treatment and
the outcomes of the former. These tend to increase in
relation to individual patient care. In the present set
up it has become much more than in the past what with
medico legal, ethical, and sociopolitical changes having
entered the arena. Clinical medicine confronts the
clinician with his ignorance daily, which is due to the
deficiencies in medical knowledge as a whole. The
imprecision and uncertainty will increase inversely
proportionate to the pressure on the time of the
physician making him spend less and less time with the
patient. There is a need to educate the new entrants to
the profession about the role of uncertainty in medical
practice as otherwise they will get overwhelmed by it
when it confronts them head on.
Another area which makes medical practice imprecise is
the impossibility to predict the future in a human system
with the present scientific methods. I have written about
this many a time in the past.The science of probabilities
started with philosopher Pascal in the 17th century, we
did not use it in medical science because of the
influence of Descartes.(4) We have now realized our
folly. To give one small example let us take the exercise
stress ECG test being done on asymptotic apparently
healthy population to predict the future outcomes. The
results are presented to the patient as positive or
negative. Both the above may be wrong because of the
large number of false positives and false negatives which
are a rule in this situation. Life becomes miserable for
most of them as either they get reassured for wrong
reasons are they are lulled into inaction where the
vulcano could erupt any time. Sense seems to have
prevailed on the thinkers and Drs. Gray Diamond and JS
Forrester have devised a probability scale to aid the
diagnosis of coronary artery disease in place of the
present positive negative paradigm which is
meaningless.(5)
Clinicians must realize that their uncertainty is at the
root of many unnecessary technologies used in diagnosis.
Diagnosis is subjective and needs, in addition to all the
textbook rules, the experience of the clinician. It is
now accepted that clinicians should develop better
communication skills and be able to share their ignorance
and doubts with the patients honestly. This is the best
method to make the patient also a partner in the decision
making process rather than keeping him in the dark and
getting into trouble later because of medicolegal
problems. Paternalism in medicine should give place to
partnerships between patients and doctors. Afterall
ignorance is universal and both the doctor and the
patient could have their legitimate ignorance although
both have their expertise in different areas. There is
one exception in this and that is in dealing with
patients who have emotional and anxiety states as their
main problem. The doctor should be able to understand
that during the initial interview and be able to diagnose
the problem then and there. The latter situation warrants
the greatest care to see that their anxiety is not
enhanced by the doctor expressing his doubts to the
patient.
With the present day knowledge explosion there will be
more confusion in the field of medical practice like in
any other field and doctors will have to be on their
guard. Simplistic market forces are not likely to work in
the medical field and society may demand much more from
the medical profession in times to come in response to
new knowledge in all fields of human endeavour. We must
enter into a new understanding with society and then face
the challenge squarely putting all our cards on the table
and not keeping any close to our chest. Honesty is the
best policy even here. Law of probabilities is our better
bet than the reductionist science paradigm. Chaos, a new
science, is making headway in all fields including
physics and we in medicine should wake up to understand
that human dynamic organism obeys only the holistic
chaotic rule, rather than the organ based specialties.(6)
All aspects of the outcomes of our interventions also
should be made known to the patients. Recent meta
analysis of Coronary bypass surgery after twelve years
showed that in terms of increasing longevity, the
operation did not benefit 84%, but in terms of relief of
pain and severe disability it did help a lot.(7) When
this is made known an asymptomatic patient will opt out
of the offer, without any risk for the clinician. One
more reason why we should be open in our attitude. To do
that with confidence we should keep in touch with new
knowledge pouring in at a phenomenal rate daily. The
knowledge changes so fast in medical field that one
should be a life long student. Change is science and
dogma is ignorance and unscientific.
" Clinicians can not afford to avoid uncertainty or
pass it off as inherent aspect of the art of medicine.
Certainty is a delusion-only uncertainty is
certain......this must be acknowledged and addressed
explicitly, especially in clinical training, if reason is
to be used most effectively to improve the quality and
cost effectiveness of clinical practice." say
Drs.Logan and Scott, from Auckland in NewZealand.(8) To
come back to my friend who thinks that medical science
has done wonders, I may have to admit that we have been
able to conquer only one disease so far, that is small
pox and it was done with the old granny wisdom and the
vaccine and not by any high tech stuff that we talk
about. Before believing that spare part surgery and the
like are the panacea for human ills, one must have some
measure of understanding of the type and cost of life for
the unfortunate patient following these procedures.
Medicine has been doing and will continue to do, the same
old dictum of Hippocrates " to cure rarely, comfort
mostly but to console always." [index]
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